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In his Viewpoint paper regarding atherosclerosis screening, Shah (1) decries the “double standard” of requiring proof of clinical benefit for imaging studies but not for clinical risk scores. However, a far more troublesome double standard relates to the treatment of hypercholesterolemia versus the treatment of other modifiable cardiovascular risk factors. The initiation of drug therapy for hypertension, diabetes, and cigarette smoking is not dependent on any calculation of the estimated risk of developing a hard cardiovascular end point within an arbitrary time period. Those with hypertension or diabetes who do not reach their treatment goals with lifestyle modification alone or those who are unable to quit smoking “cold turkey” are appropriately treated with drug therapy. In fact, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) explicitly states that it “does not stratify hypertensive individuals by the presence or absence of risk factors … in order to make different treatment recommendations … . JNC 7 suggests that all people with hypertension … be treated” (2). Among the modifiable cardiovascular risk factors, only hypercholesterolemia requires anything other than the presence of the risk factor itself to prompt treatment.

Shah (1) explicitly raises this issue himself, but dismisses the unconditional treatment of hypercholesterolemia with statins because of concerns regarding cost, need for lifetime use, and intolerance. However, these concerns are certainly no different than those associated with drug treatment for hypertension or diabetes, issues not addressed by Shah (1). Moreover, statins are among the safest medications ever introduced (3) and are generally no more expensive or risky than many widely prescribed antihypertensive and antidiabetic drugs. Most remarkably, Shah (1) is not in favor of unconditional treatment of hypercholesterolemia, in part because statin therapy “only addresses about 30% to 50% of the risk.” It is difficult to understand why a reduction of risk of this magnitude for a condition that accounts for nearly one-third of all deaths worldwide would represent anything other than a powerful endorsement of treatment. It is time to embrace the unconditional treatment of hypercholesterolemia and bring lipid treatment in line with the well-established treatment paradigms for other cardiovascular risk factors.

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